Suffolk APHR 2022

Annual Public Health Report (APHR) on Core20PLUS5.

Core20PLUS5 is way of improving outcomes, and reducing health inequalities –the avoidable, unfair and systematic differences in health between different groups of people.

Core20PLUS5 offers a way of reducing inequalities by targeting prevention work.

We can use Population Health Management data and approaches in ways which are responsive to the needs of the Suffolk population.

It enables us to move from data to action, and have much greater impact than could be achieved previously.

Core20Plus5 triangle diagram. Diagram showing arrows pointing in both directions to link Core20plus5 (at the top) and Prevention (bottom left) and Population health management (bottom right)..


This year, the focus of the Director of Public Health's Annual Report for Suffolk is Core20PLUS5.

Core20PLUS5 is a way of improving outcomes, and reducing health inequalities –the avoidable, unfair and systematic differences in health between different groups of people. We focused on health inequalities in the 2020 Director of Public Health's Annual Report for Suffolk - but through a different lens, the voices of our community. The legacy of this work must carry on as we continue to tackle existing health inequalities and face new challenges following the COVID-19 pandemic and the emerging cost of living crisis.

With the formal statutory establishment of ICSs (Integrated Care Systems) across England in July 2022, and as a core member of the Integrated Care Partnership, the focus is on all of us, working collaboratively as a system, to ensure we are working to improve care, health and wellbeing of the population, whilst working with local communities. Many organisations are already working extensively to reduce inequalities – recent examples include work to address inequalities in COVID-19 vaccine access by the Suffolk and North East Essex Integrated Care Board, West Suffolk Foundation Trust and East Suffolk and North East Essex NHS Foundation Trust’s work to review and manage waiting lists in light of inequalities, and the COVID-19 and subsequent Protect Now work in Norfolk and Waveney. We must continue to build on the excellent ways of collaborative working we fostered during the pandemic to address both the new threats to people's health and wellbeing we now face, and to tackle the long-standing and multiple areas of disadvantage which have blighted people's life chances and fostered inequality for too long.

Whilst it is an NHS initiative designed for use by our Integrated Care System (ICS) areas, the goals of Core20PLUS5 mirror our own priorities within Public Health and Communities Suffolk – to improve health and wellbeing and reduce inequalities. I recognise two ICS areas cover Suffolk (encompassing the neighbouring areas of Essex and Norfolk), and the focus of my report is on the Suffolk population. However, it is for this reason, that there is an even greater need for cross-system working – to share ideas, good practice and to join up even when our geographical boundaries don’t always align!

This report provides an overview of what Core20PLUS5 is, and what we, and everyone in the wider Suffolk system of health and care, can do to continue long-established work around reducing health inequalities and to tackle them using new approaches including population health management and Core20PLUS5.

It is only by working together, that we can close the health inequality gap and ensure Suffolk has: healthier people, healthier places and healthier futures.


The Integrated Care Boards (ICBs) covering Suffolk should:

  1. Use this Annual Public Health Report as an evidence base for tackling inequalities through Core20PLUS5.
  2. Ensure clinical and managerial leadership and accountability for reducing health inequalities through Core20PLUS5 are clear.
  3. Agree and adopt the ‘plus’ populations recommended in this report for routine consideration and action across Suffolk to reduce inequalities in outcomes, access and experience – coastal communities; rural communities; people from minority ethnic communities; and groups and individuals facing the sharpest health inequalities and worst outcomes.
  4. Ensure Core20PLUS5 is included in all Integrated Care Board (ICB), Alliance, Integrated Neighbourhood Team (INT) and provider plans and strategies, with additional PLUS populations agreed at area and system level where appropriate, and that it drives action.
  5. Ensure population health management data, tools and capacity are available to facilitate work on Core20PLUS5 across the health and care system, enabling Alliances and front-line integrated teams to identify their own local and hyperlocal ‘PLUS’ populations, in order to reduce local health inequalities.
  6. Recognise that there is a clear need for a renewed focus on prevention, ensuring there are clear plans of action for maximising prevention opportunities, with a particular focus on people in mid-life.
  7. Ensure the current levels of performance with regard to the Core20PLUS5 populations and clinical pathways are understood, including local data covering all the areas of Core20PLUS5, and monitor the data over time to provide assurance of improvement.

Through these recommendations, and the work to progress Core20PLUS5 more broadly, we must all ensure we don’t inadvertently widen local health inequalities, and that all communities benefit from the activity undertaken, not just those who are relatively easy to reach. This may require more explicit focus, action and investment in some parts of Suffolk than others.